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Zakkia et al., J Preg Child Health 2015, 2:4
Journal of P

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Journal of Pregnancy and Child Health DOI: 10.4172/2376-127X.1000176

ISSN: 2376-127X ild Health

Research
Research Article
Article OpenAccess
Open Access

Success Rate of Cervical Cerclage in Preventing Preterm Labour

Zakkia Khan1*, Radhia Khan2 and Anwar Khan Wazir3
1
Gynea Ward, Women and Children Hospital, Bannu, Pakistan
2
Department of Biochemistry, Khyber Girls Medical College, Peshawar, Pakistan
3
Department of Physiology, Khyber Girls Medical College, Peshawar, Pakistan

Abstract
Objective: To determine the success rate of cervical cerclage in preventing preterm deliveries in patients having
cervical incompetence.
Study design: Descriptive (cross sectional) hospital based study.
Place and duration of study: Department of obstetrics and Gynecology, Khyber Teaching Hospital Peshawar.
One year from 1st January 2013 to 1st January 2014.
Methodology: Seventy five subjects were selected by consecutive (non-probability) sampling technique. The
sample size was calculated by keeping success rate of cervical cerclage as 73.3%, confidence level of 95% and
precision of 10%. All the patients were having a history of two or more recurrent midtrimester abortions or preterm
deliveries and were subjected to cervical cerclage (McDonald suture). Age, gravidity, parity of the patients, gestational
age at delivery, weight of the baby and apgar score was determined. Success rate of cervical cerclage was calculated.
Results: The average age, Gravida and para of the patients were 28.35± 3.96, 5.33±2.36 and was 1.7±1.46
respectively. Results were evaluated on the basis of pregnancy prolongation. Most of them (69%) delivered at term
(>37 weeks), 17.3% had preterm deliveries (28-37weeks) and 17.3% had abortions (12-28weeks). Sixty four percent
of babies had birth weight of 2.5kg or more and 36.0% had birth weight of less than 2.5kg. Fetal survival rate (good
apgar score) was 76%. Overall success rate of cervical cerclage was 80%.
Conclusion: Application of cervical cerclage in pregnant women with previous preterm delivery reduces the
preterm delivery rate at a reasonable cost with no additional risk to the mother and the fetus.

Keywords: Cervical cerclage; Preterm
incompetence; Transvaginal ultrasonography
Introduction
Cervix is labeled incompetent when it is unable to retain an
intrauterine gestation until term. It plays a fundamental role in
supporting a pregnancy and preventing ascending infection. Infection
is associated with preterm delivery in half of the cases [1]. Whatever
the etiology of preterm delivery, dilation of the cervix is a common end
point.
Preterm delivery is associated with immediate and long term
neonatal complications. Immediate complications include infection,
respiratory distress syndrome, hyper bilirubinemia and necrotizing
enterocolitis. The long term complications include cerebral palsy, nuero
developmental delay and chronic lung disease [1].
Cervical cerclage is a surgical procedure involving suturing the
cervix with a purse type stitch to keep it closed during pregnancy
[2]. Cervical cerclage can be done preventably at 12 to 14 weeks
before the cervix thins out. Cervical insufficiency has no consistent
definition, but is usually characterized by dilatation and shortening of
the cervix before the 37th week of gestation in the absence of preterm
labour, and is most classically associated with painless, progressive
dilatation of the uterine cervix in the second or early third trimester
resulting in membrane prolapse, premature rupture of the membranes,
midtrimester pregnancy loss, or preterm birth. Cervical insufficiency
arises from the woman’s inability to support a full-term pregnancy due
to a functional or structural defect of the cervix [3].
delivery; Cervical Cervix is labeled incompetent when it is unable to retain an intrauterine
gestation until term. It plays an important role in supporting a pregnancy
and preventing ascending infection. Infection is associated with early
preterm delivery in half of this cases [3]. Whatever the etiology of
preterm delivery; dilation of the cervix is a common end point.
Diagnosis is mostly clinical. Past obstetrical histories of recurrent
mid trimester miscarriages or preterm delivery are the basis of
cerclage. Perspeculum or digital examination may show patulous or
bulging membranes and may confirm diagnosis but have not shown
to improve outcome [4]. Ultrasound is the principal modality used
during pregnancy to measure cervical length and opening, in non-
pregnant ladies Hegar’s test, Foley’s catheter extraction, Hysterogram
and Hysteroscopy can be used. Cervical resistance index and cervical
compliance score are other investigations [4].
Previous preterm delivery has been shown to be a major risk factor
for preterm delivery. History of one previous preterm delivery has
been shown to be associated with a recurrence risk of 17 to 40%, the
risk increasing with the number of preterm birth [5]. More than 85%
*Corresponding author: Zakkia Khan, Assistant Professor, Gynea Ward,
Women and Children Hospital, Bannu, Pakistan, Tel: 0333-9150924; E-mail:
alamkhandr@yahoo.com
Received: December 04, 2014; Accepted: June 17, 2015; Published: June 23,
2015
Citation: Zakkia K, Radhia K, Anwar Khan W (2015) Success Rate of
Cervical Cerclage in Preventing Preterm Labour. J Preg Child Health 2: 176.
doi:10.4172/2376-127X.1000176

Main indications of cervical cerclage are previous second trimester Copyright: © 2015 Zakkia K, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
pregnancy loss or delivery that occurred with few or no contractions use, distribution, and reproduction in any medium, provided the original author and
and cervical trauma or injury leading to cervical incompetence [2]. source are credited.

J Preg Child Health

ISSN: 2376-127X JPCH, an open access journal Volume 2 • Issue 4 • 1000176
Citation: Zakkia K, Radhia K, Anwar Khan W (2015) Success Rate of Cervical Cerclage in Preventing Preterm Labour. J Preg Child Health 2: 176.
doi:10.4172/2376-127X.1000176

Page 2 of 4

long term disabilities and in otherwise healthy babies and 75% of death Cervical cercalage was performed under general anesthesia using
among newborns occur as a result of preterm delivery [6]. Cerclage has Macdonald’s techniques [17]. After surgery they were observed in the
been reported to improve cervical length and restore cervical anatomic ward for two days. Antibiotics prophylaxis with amoxicillin 500mg 8
relationships [7]. It has been suggested that cerclage placement closer hourly and metronidazole 400mg 8 hourly 5 days and pentazocine 60
to internal or may be associated with improved perinatal outcome [8]. mg 8 hourly for 24 hours were given. After discharge they were seen
a week later at the antenatal clinic and during routine antenatal visits
Since the development of transvaginal ultrasound, short cervical
thereafter. In absence of complications, the cercalage stich was removed
length has been recognized as one of the most accurate predictor of
at 37 completed weeks. However, the stich was also removed earlier if
preterm birth. Short cervical length i.e less than 25 mm is considered
there were persistant contractions not amenable to tocolytic drugs or if
incompetent when uterine contractions are absent [9]. Transvaginal
there was rupture of fetal membrane.
ultrasound of the cervix has been studied as a screening test for
this important condition. It has been shown to be safe, acceptable Confounding variables like genital tract infections, uterine
and reproducible [10]. It recognizes an early asymptomatic phase anomalies, fibroid uterus and contraceptive device were controlled on
that precedes symptomatic preterm labor or pre-mature rupture the basis of detailed history, physical examination and performing ultra
of membranes better than manual examinations [11] and has been sonography from radiology department of Khyber Teaching Hospital,
shown to be one of the best predictor of preterm birth. A screening test Peshawar. Antenatal checkups were done according to protocol. During
such as transvaginal ultrasound can be beneficial only if an effective antenatal visits any complications arising were treated accordingly.
intervention can prevent the outcomes. The only two previous trials on Those patients presenting in labour room, their detail examination
cerclage as an intervention to decrease preterm birth in women with including per abdominal, per vaginal if indicated and per speculum
a short cervix that was found on transvaginal ultrasound have shown were done. Gestational age at the time of delivery, Apgar score at 5min
contradictory result [12,13]. and weight of the baby were noted. All the data was collected by using
Performa questionnaire.
The effectiveness of cervical cerclage in women with cervical
incompetence using Mc Donald procedure increased the rate of term All the collected information was entered in software SPSS version
deliveries to 95.4%. The mean gestational age at delivery was 35 weeks 10 and analyzed through its statistical package. Quantitive variables like
[14]. 7.5% of miscarriages, 18.7% of premature deliveries, 73.7% of age, Gravidity, parity was presented as mean and standard deviation.
term deliveries and 85.1% of fetal survival rate (good apgar score) were Qualitative data like gestational age at the time of delivery, weight of
observed after cervical cerclage in patients having sonographically the baby and Apgar score were presented in the form of frequencies
incompetent cervix [15]. and percentages. Success rate of the term deliveries after application of
cerclage was calculated. Results were in the form of tables.
Observational studies show that in classical cases with a severely
traumatized or virtually absent cervix, neonatal survival may be up to Results
93% after effective cerclage as compared to 27% before the cerclage [16].
This was a descriptive study of 75 patients to whom cervical cerclage
Methodology was applied based on having history of previous two mid trimester
losses or preterm deliveries in Obstetrics and Gynecology, Department
It was a cross sectional descriptive study and was completed in
of Khyber Teaching Hospital, Peshawar, Pakistan.
1 year, January 2013-January 2014. The study was conducted in the
Department of Obstetrics and Gynecology, Khyber Teaching Hospital, Table 1 indicates the socio-demographic characters of the patients
Peshawar, Pakistan. The sample size was 75. The sample size was with cervical cerclage. Average Age of the patients was 28.35 ± 3.96
calculated, keeping the success rate as 73.3% with cervical cerclage, years. Most of the patients 42 (56%) were in the age group of 26-30years,
confidence level of 95% and precision of 10%. The sample technique 19 (25%) were in the age group of 20-25 years, 9(12%) were in the age
was non-probability consecutive sampling. group of 31-35 and 5(6.7%) were of age >35years. Average Gravida
of patients was 5.33 ± 2.36. Among the 75 patients most of them 46
All those pregnant women who were having previous history of (61.3%) were of gravida 2-5, 23 (30.7%) were gravida 6-9 and 6(8%)
preterm deliveries and cervical length of less than 25 mm on trans were more than 9 gravida. Average parity of patients was 1.7+1.46.
vaginal ultrasound were included in the study. The exclusion criteria
for the study were that pregnant women having preterm deliveries due Maternal characters Frequency Percent Cumulative Percent
to pre eclampsia and eclampsia (iatrogenic preterm delivery because Age (Years)
20-25 19 25.3 25.3
patients are induced), multiple pregnancies (preterm delivery due to
26-30 42 56.0 81.3
over distended uterus) and polyhydramnias (preterm delivery due to 31-35 9 12.0 93.3
pre labour rupture of membranes). >35 5 6.7 100.0
Gravida
Patients were enrolled from the antenatal clinic of Khyber Teaching 2-5 46 61.3 61.3
Hospital, Peshawar and included in the study after fulfilling the 6-9 23 30.7 92.0
>9 6 8.0 100.0
diagnostic criteria of having history of preterm deliveries or having
Parity
cervical length of less than 25 mm on trans vaginal ultrasound. 0-2 52 69.3 69.3
After getting permission from the ethical committee, an informed 3-5 22 29.3 98.7
written consent was taken as part of ethical practice. Age, obstetrical >5 1 1.3 100.0
Gestation Age
history, history of current pregnancy, gestational age was recorded.
12-28 weeks 13 17.3 17.3
Trans vaginal ultrasound was taken into account. To control any 29-37 weeks 13 17.3 34.7
bias ultrasound was done from the same ultasonographer and using >37 weeks 49 65.3 100.0
standardized ultrasound facility available in the hospital. Table 1: Socio-demographic features of the patients with cervical cercalage.

J Preg Child Health

2376-127X JPCH, an open access journal Volume 2 • Issue 4 • 1000176
Citation: Zakkia K, Radhia K, Anwar Khan W (2015) Success Rate of Cervical Cerclage in Preventing Preterm Labour. J Preg Child Health 2: 176.
doi:10.4172/2376-127X.1000176

Page 3 of 4

Among the 75 patients most of them 52 (69.3%) were having parity
of 0-2, 22 (29.3%) were having parity of 3-5 and 1 (1.3%) were having
parity of >5. Gestational age after application of cervical cerclage was
analyzed. Among the 75 patients, 49 (65.3%) were delivered at term
(>37weeks), 13 (17.3%) had preterm deliveries and 13(17.3%) also had
abortions.
Table 2 indicates the maternal and fetal outcomes of the patients with
cervical cerclage. Three out of 75 patients (4%) had placental abruption
and 1 out of 75 patients (1.3%) developed chorioamnionitis between
the gestational ages of 28-37 weeks due to which cervical cerclage was
removed electively at 34 weeks. Most of the patients 60 (80%) were
having normal vaginal delivery while 15 (20%) went through caesarean
section. Among the 75 patients, weight of the baby after application
of cervical cerclage was observed. Most of them 48 (64.0%) had birth
weight of more than or equal to 2.5 kg while 27 (36%) had infant birth
weight of <2.5 kg. Apgar score at 5 minutes (fetal survival) of all the
75 patients was observed. Most of them 57 (76.0%) had Apgar of more
than 7 while 18 (24%) had Apgar of less than 7.
75) after application of cervical cerclage delivered at a gestational age
of >37 weeks, 17.3% (13 out of 75) had preterm deliveries i.e. they
delivered at a gestational age between 28-36weeks and in 17.3% (13
out of 75) pregnancy loss occurred i.e. patients aborted at gestational
age between 12-28 weeks. This is in accordance with the study done
by Shamshad et al7 who conducted a descriptive cross sectional study
over a 2 years period on patients having history of 2 or more recurrent
mid trimester abortions/preterm deliveries. They reported 73.7% of
term delivery after application of cervical cerclage, 18.7% of premature
delivery and 7.5% of miscarriages. Another study by Clen et al [18] also
demonstrated 76% of term deliveries, 12% preterm deliveries and 10%
of abortions. The slight difference of term delivery in our study (65.3) as
compared to the 73.7% reported by Shamshad et al7 and 76% reported
by Clen et al. [16] was because we took the cut off value of term delivery
at >37 weeks gestation while they considered 35 weeks gestation as term
pregnancy. Moreover we had to remove the cerclage electively from 2
out of 75 patients (2.6%) at 35 weeks gestation due to the complain of
decrease fetal movements as they had bad previous obstetrical history.

Table 3 indicates the success rate of cervical cercalage in different
age groups. The overall success rate of cervical cerclage was observed in
60(80%) cases, among which the success rate was high in the age group
of less than 30 years.
Discussion
Cervical cerclage is applied to prevent pretem delivery and hence
the complications of preterm delivery. Cervical incompetence is
recognized in reproductive age group due to its clinical impact on
the reproductive function which is apparent from our study which
represents 20-40 years age range.
Most of our patients 52 out of 75 (69%) were of low parity (0-2)
which is quite reflective of the condition that leads to adverse outcome.
The same is supported by a study done in 2004 by shennan A [15].
Good Apgar score at five minutes after birth is a sign of better
survival of neonate. In our study 57 out of 75 patients (76%) had good
Apgar score at 5 minutes i.e. more than 7. This means that cervical
cerclage improves fetal survival rate which is also supported by previous
studies [19].
Low birth weight babies i.e. <2.5 kg have high perinatal morbidity
and mortality. In our study 48 out of 75 (64%) had birth weight of more
than or equal to 2.5 kg which shows that cervical cerclage improves
neonatal survival and decrease perinatal morbidity. This has also been
demonstrated by Ezechi OC in a study conducted in 2004 [1] which
demonstrated 71% of babies having birth weight of >2.5kg. This slight
difference in our study may be due to the fact that the people of our
setup were poor and were having low socioeconomic status which
might had contribute to the low birth weight babies.

It was observed in the study that 65.3% of the patients (49 out of Overall success rate of cervical cerclage was found to be 80% which
was stratified among the age which shows that the success rate was high
in the age of less than 30 years. This is mainly because as age increases
Variables Frequency Percent Cumulative Percent reproductive functions decreases. This is also supported by previous
Placental abruption studies [20,21].
Yes 3 4 4
No 72 96 100
Conclusion
Chorioamnionitis
Yes 1 1.3 1.3 Past history of recurrent mid trimester abortions or preterm
No 74 98.6 100
deliveries when supported by transvaginal ultrasonography forms
Mode of delivery
Vaginal delivery 60 80 80
a reliable basis for diagnosis. Selective use of cervical cerclage had
Caesarean section 15 20 100 important effect in prolongation of pregnancy and improving fetal
Weight of babies survival rate. History alone is not an indication for prophylactic
< 2.5 27 36.0 36.0 cerclage. Although transvaginal ultrasonography identifies women at
≥ 2.5 48 64.0 100 risk of preterm delivery but it can not discriminate between different
Apgar Score pathologies. Short cervix alone is also not an indication for therapeutic
<7 18 24.0 24.0
≥7 57 76.0 100 cerclage. Serial transvaginal ultrasound measurement of cervical length
in women with risk factors can identify those women truly at high risk
Table 2: Maternal and fetal outcomes of the patients with cervical cercalge
of preterm delivery.
Success rate We believe cerclage therapy should be considered an ongoing
Age in years Total
No Yes investigational process and recommend an evidence-based approach to
20-25 5 (6.7%) 14 (18.7%) 19 (25.3%) identify appropriate treatment for women with sonographic evidence
26-30 8 (10.7%) 34 (45.3%) 42 (56.0%) of cervical incompetence.
31-35 2 (2.7%) 7 (9.3%) 9 (12.0%)
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J Preg Child Health

2376-127X JPCH, an open access journal Volume 2 • Issue 4 • 1000176
Citation: Zakkia K, Radhia K, Anwar Khan W (2015) Success Rate of Cervical Cerclage in Preventing Preterm Labour. J Preg Child Health 2: 176.
doi:10.4172/2376-127X.1000176
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